HMO Health Plan Insurance Coverage – Tips To Get Your Claim Accepted

Anyone with an HMO insurance plan knows the story all too well. You jump through every hoop they ask you to jump through – you see the primary care physician before you go to a specialist that you already knew you had to go to. And then you go to the specialist you need to go to and then you wait months for approval from your health care provider before having an important and time-sensitive surgery … and on and on.
What’s even more maddening, though, is that you can do exactly what they ask of you and find out down the road that they still somehow found a way to deny your claim. What does an insured person have to do to use this so-called insurance, anyway?

Avoid Claims Problems by Following These Tips
Nothing is fool-proof these days, but heeding the following suggestions can go a long way toward eliminating unforeseen problems with getting your plan to pony up – or fighting back when they won’t do the right thing.

First and foremost, don’t be shy about filing a grievance if you think you’ve been unjustly charged for medical services. Insurance companies make a whole lot of money off of people who allow themselves to be bullied into accepting unjust charges. In many states, grievances are brought to an external review board that will look at the situation objectively. If the charge is upheld, take it a step further and go to the officials in charge of regulating your health plan.

Annoying as it might be, double check every bit of possible coverage before seeing a physician. Even if your plan’s handbook states that something is covered, take the time to make any necessary phone calls (to the insurance provider, physician’s office, etc.) and ask anyway. Take notes on any conversation you have with your insurer’s customer service department – the representative’s name, the date of the conversation, and any relevant details. Should there be a later grievance, you can refer back to this conversation and possibly use the information to prove you were misled.

If you have employer-provided insurance and find out that your benefits have changed without your prior knowledge (just in time for that cyst removal you had scheduled), talk to the human resources department and find out if your situation is still covered in any contingency that the company has with the insurer. If not, at least ask for an assurance that this will never happen again, as it’s imperative you be notified in advance of any changes to your coverage.

In certain instances, employer-provided healthcare plans can work to your advantage. Depending on the size of the company account, your human resources department might be able to negotiate certain things with the insurance company. Many employers aren’t even aware they have this option, so don’t hesitate to bring it to their attention and have them look into it. If they can save you thousands, it’s worth pushing them to stick their necks a little, isn’t it?

Recurring Healthcare Coverage Problems – Time to Jump Ship?
It’s getting harder and harder to find a plan that’s worth the premiums, no doubt about it. If you have repeated problems with your insurance company, use the Internet as a resource to find out if other people have been able to resolve similar issues by using any particular method. If you can’t figure anything out to resolve matters, have filed grievances and been denied, have gone through your human resources department (if applicable), and are still having significant problems … well, what’s the point of having that insurance carrier?
It’s time to look for a new insurer, and there are many sites that have comprehensive consumer grading systems for health plans these days. Use these sites to your advantage, and don’t hesitate to pay an extra few dollars a month for a plan that’s better suited to your situation.
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